Endpoints of Resuscitation
William C Watson, MD
William
C Watson MD
Medical Director of Trauma
Advocate Condell Medical Center
The Surgeons of Lake County
Libertyville, IL. 60048
Advocate Condell
Medical Center
Shock
A state of inadequate tissue perfusion
Septic
p
Anaphylactic
Hemorrhagic
g
Neurogenic
Cardiogenic
Historyy
According to Greek history, blood is one of 4 humors
black bile, yellow bile and phlegm
1665 – Richard Lower transfused blood between 2 animals
1667 – transfused sheep blood into mental patient
Both experiments were successful
Tractatus de Corde (1669)
Historyy
1668 – British Royal Society banned transfusion
1901 Landsteiner
1818 Blundell
Lewinson 1915
Recent
No new changes in resuscitation fluids in over 100 years!!!
Synthetic hemoglobin?
Synthetic hemoglobin?
Benefits
Challenges
Widely available
Availability
Long shelf life
Immune response
No refrigeration
Short ½ life
Universal
Increase oxygen affinity
No infectious risks
Vasoactive
Offloads oxygen quickly
So forget this for now…
The Concept of Resuscitation
p
“Normal”
No resuscitation
Small volume resuscitation
Auto‐transfusion
Blood Products
No Resuscitation
Not really true.
Based on theory that if blood pressure is increased to normal, the rate of bleeding increases
Newly formed clots are disrupted
Theory of “scoop and run”. Mattox 1994
No Resuscitation
Hospitals are relatively close with low transport times
Control the bleeding. Then resuscitate
ALOT of studies
ALOT of studies. I mean alot
In the presence of hemorrhage, no resuscitation and li it d (
limited (small volume) resuscitation significantly ll l
)
it ti
i ifi tl
reduced overall blood loss subsequent blood t
transfusions.
f i
1994
Patients randomized to
normal resuscitation
versus “none”.
Only real difference was
time to arrival at hospital
2600cc versus 386cc fluid
No outcome differences or
survival benefits of more IVF .
“Scoop and run” was just as
good as standard resuscitation
No Resuscitation
So why aren’t we doing this?
The concept has not proven beneficial in Th
th
t
b
fi i l i
general. There are several studies for and against not resuscitating. It’s an ongoing y
gy
controversy that continues to rear its ugly head
Small Volume Resuscitation
Large volumes of crystalloid may be bad?
Pulmonary edema
Compartment syndromes
Dilution of coagulation factors
Small Volume Resuscitation
Large molecules or large osmotic forces will
stay in the intravascular space better than
crystalloid
y
thus expanding
p
g the intravascular
volume.
Hypertonic
H
t i S
Saline/Acetate
li /A t t
Hetastarch
Alb i
Albumin
Hypertonic Saline (3%)
yp
( )
Derived from military use
Impossible to carry large volumes in the field
Longer intravascular half life
Expands blood volume 1:1.5
Reduces intra-cranial pressures
Little immuno-activation
Role in civilian population still to be determined…
Hypertonic Saline (3%)
yp
( )
Many animal studies revealed actual increases in EBL when HSD was used. It worked too well…
Acetate was substituted for saline
Added benefit of being a buffer
Added benefit of being a buffer
Hypertonic Resuscitation
yp
Despite potential advantages, clinical trials of hypertonic resuscitation early after injury have failed to demonstrate significant benefit for resuscitation of hemorrhagic shock, and although there is no difference in overall mortality, there appears to be a trend toward earlier mortality among those receiving hypertonic fluids. DB Hoyt 2012. Adv Surg
Hetastarch
Large carbohydrate molecule
Increases oncotic pressure
Starlings Law
g
Hetastarch (Hespan)
(
p )
Concluded that initial resuscitation with C
l d d th t i iti l
it ti
ith
Hetastach was associated with reduced mortality without coagulopathy.
t lit ith t
l
th
JACS 2010
Hetastarch (Hespan)
(
p )
Due to increased mortality and renal dysfunction, hetastarch should be avoided y
,
in initial trauma resuscitation.
AJS 2011
Albumin
There are no studies looking at albumin as a resuscitation fluid
Expensive
Blood product
Shelf life
Albumin
The only surgical patients that benefited from albumin were CV, liver failure and burn patients
Patients with head injury treated with albumin
had significantly high mortality rates.
2010
Albumin
DON’TT USE IT
DON
USE IT
2010
Small Volume Resuscitation..
The Cochran Library 2012
Auto‐transfusion
The perfect fluid theoretically
Obvious blood type match
Great oxygen carrying capacity
Great oxygen carrying capacity
Low cost?
Infectious complications?
p
Arch Surg 2010
Autotransfused (CellSaver)
Autotransfused
(CellSaver)
Used less donated blood (4u v 8u)
Decreased cost ($1616 v $2584)
N i f ti
No infectious complications
li ti
Experience gained from military
G t t
Great outcomes and survival data
d
i ld t
More to come…
2006
We potentially have all these ll h
ll h
options but what do I do with
options, but what do I do with them?
How do I tell if the patient is
p
RESUSCITATED?
Endpoints of Resuscitation
The goal of resuscitation is restoration of cellular perfusion to meet metabolic needs
meet metabolic needs
With t
Without over or under resuscitating the patient
d
it ti th
ti t
What is the best way to measure resuscitation?
Endpoints Resuscitation
Traditional Clinical Parameters (VS, UO, mental status)
Traditional Clinical Parameters (VS, UO, mental status)
Invasive hemodynamic monitoring (CVP, PAP, CI, DO2)
Metabolic Parameters (base deficit, lactate)
Expensive Gadgets (Tonometry, Trancutaneous O2)
Endpoints Resuscitation: Gadgets
Endpoints Resuscitation: Clinical
Blood Pressure (HR) is non‐predictive
Blood Pressure (HR) is non
predictive of state of of state of
tissue perfusion in the acute traumatic setting
Dabrowski, et al 2006
Mental status is too variable
Endpoints Resuscitation: Clinical
Oliguria is one of the earliest signs of inadequate
Oliguria is one of the earliest signs of inadequate perfusion. Responses to urine output to intervention can guide resuscitation*
*Must consider confounding factors
such as diabetes insipidus, chronic
renal failure, diuretic therapy
Endpoints Resuscitation: Invasive
Swan Ganz Catheter
Endpoints Resuscitation: Metabolic Parameters
We draw a lot of labs on trauma patients. Which ones are most important?
Endpoints Resuscitation: Metabolic Parameters
Lactate – hypoperfusion leads to inadequate oxygen delivery shifting l
hf
cells to anaerobic metabolism. Lactate is a b l
byproduct
Endpoints Resuscitation: Metabolic Parameters
Unfortunately, not specific U
f t
t l
t
ifi
in detecting abnormal regional perfusion Best to
regional perfusion. Best to be followed as a trend. Patients who cannot
Patients who cannot normalize lactate levels have higher mortality (86% v
higher mortality (86% v. 25%) Vincent, et al. Crit Care Med. 1983
Endpoints Resuscitation: Metabolic Parameters
Base Deficit – measurement of the buffering capacity of bl
blood. Reflects anaerobic fl
b
metabolism and depth of h
hemorrhagic shock. A base h
h k b
deficit > 6 mmol is a marker of severe injury
f
Endpoints Resuscitation: Metabolic Parameters
Can be confounded by multiple factors. ETOH l l
levels and hyperchloremia h
hl
but are still predictable.
Bicarbonate levels correlate well with base deficit
Alright! What do we do?
Alright! What do we do?
Standard parameters do not adequately quantify the degree of derangement in trauma patients. Base deficit, lactate and gastric pH can be used to identify f
l
b
f
the need for continued resuscitation
The better the oxygen delivery, the improved chance yg
y,
p
for survival.
EAST 2003
www.east.org
Alright! What do we do?
Alright! What do we do?
1.
1
2.
3.
4.
5.
Stop the bleeding
Stop
the bleeding
Resuscitate with crystalloid (1 ‐2 liters)
Start PRBCs
If more than 3‐4 units, start FFP
Utilize gastric pH, base deficit and lactate levels to gguide resuscitation. ATLS
What I do
What I do
1.
1
2.
3.
4.
5.
Stop the bleeding
Stop
the bleeding
Resuscitate with crystalloid (1 ‐2 liters)
Start PRBCs
1:1:1 transfusion with PRBC/FFP/Plts
Utilize urine output, base deficit and lactate levels to guide. g
Consider mass tranfusion poslicy
Conclusion
Ideal fluids and resuscitation parameters should be reliable , safe and cheap. Optimal fluids and endpoints are difficult to
Optimal fluids and endpoints are difficult to determine and the search for a common endpoint is difficult and unrealistic.
d i i diffi l
d
li i
Current guidelines probably offer the best g
p
y
approach
Questions?